Data Across the Continuum of Care

Nursing Symposium, February 11, 2019

Becky Fox, MSN, RN-BC, Chief Nursing Informatics Officer

Stephanie H. McIntyre, MBA, RN-BC, CHPQ, Assistant Vice President, Information & Analytics Services

Becky Guess Fox and Stephanie H. McIntyre have no real or

apparent conflicts of interest to report.

Conflict of Interest

• Data challenges across the continuum

– Current healthcare landscape and challenges in US

– How has data landscape has changed?

– Data across the continuum drives value

– Alignment and practical applications

– Data challenges

• Define how data can be used to change individual behavior

– Stakeholders

– Comprehensive Assessment

– Examples

– Suggested Steps

Agenda

• Discuss how nurse informaticists can ensure proper systems translation and

communication

– Definition

– How?

• Identify essential organizational players and their vital roles in transitional care

– Key players

– Thinking differently

• Provide key takeaways in identifying source data for specific transitions of

care

– Data sources

– Care Management across the continuum

• Lessons learned from our organization

Agenda (continued)

• Identify potential challenges with data flow across the continuum

• Define ways data can be used to change individual behavior

• Discuss how nurse informaticists can ensure proper systems

translation and communication

• Identify essential organizational players and their vital roles in

transitional care

• Provide key takeaways in identifying source data for specific

transitions of care

Learning Objectives

Data challenges across the

continuum

Healthcare Challenges in the US

 250,000 deaths per year due to medical error

 Comprises 18% of GDP . . . and increasing

 US quality ranks low when compared to other developed

countries

 $3.06 trillion spent in 2014*; growing at rate of 5.8 percent**

 “Waste” = $765 Billion (30% of total):

– $210B – unnecessary services

– $190B – excessive administrative costs

– $130B inefficiently delivered services

– $105B prices too high

– $75B fraud

– $55B – missed prevention opportunities

 Over 54 Million Enrolled in Medicare^; 78 Million by 2030 (last

year of baby boomer eligibility)

Sources: *Office of the Actuary at the Centers for Medicare and Medicaid Services; **National Health Expenditure Projections, CMS; ^Kaiser Family Foundation;

^^Facts on Medicare Spending, Kaiser Family Foundation; ^^^2013 Actuarial Report, Department of Health and Human Services

How has the data landscape changed?

Data Across the Continuum

LONGITUDINAL PERFORMANCE MANAGEMENT

(Population Health Management)

Payers

Physician

Orgs

CINs

ACOs

Employers

Data across the continuum

Connect the

continuum

Empower patients,

care teams,

and organizations

Facilitate

knowledge-driven

care

and continuous

learning

Outpatien

Ambulatory

Home

Health

Acute

Care

SNF

Lab

Patient

Epic

Cerner EMR1 EMR 2 EMR 3

EMR 4 EMR 5

Data Repository & Master Patient Index

Population Health Platform

Care

Transitions

Care

Gaps/Healt

Disparities

Risk

Stratificatio

Chronic Care

Management

Wellness

Support

Alignment

of Social

Services

Disease

Managemen

Utilization

Need to focus alignment of data that will enable us to:

• Assist in strategic decision-making

• Risk stratify patients and populations

• Analyze potential opportunities for care improvement and cost reduction

• Assess gaps in care delivered

Alignment of Data and Information

What is the practical application?

Interoperability

•Variability in

systems

•Expense to

aggregate and

normalize

•Timeliness

Security and

Privacy

•Risk

•Data Use

Agreements

•May limit access

Applicability

•Turning data into

actionable

information

•Embedding

meaningful data

into workflow

•Emerging patient

engagement

technologies

Data Quality

•Provider

Attribution

•Data Validation

•Patient

Generated Data

•Data Governance

Culture

•Perfect vs Good

•Overengineering

•Crawl before

Walking

Data Challenges

Using Data to Change Behavior

Stakeholders and things that influence

• All stakeholders benefit

when patients reach their

optimum level of wellness,

self-care management, and

functional capability. These

stakeholders include the

patients, their support

systems, and the healthcare

delivery system providers of

care, the employers, and

payors.

Ability to

Self-

Care

Developmental

State

Resource

availability

Health State

Family system

factors

Sociocultural

orientation

Age

Comprehensive Assessment

Medication Adherence Assessment and Evaluation

Environment, Resources and Services

Financial Health

Fitness Habits

DME/Functional Evaluation

Skilled Services Evaluation

Systems Evaluation

Barriers to Care

PHQ-9 and Referral to BHI if warranted

Readiness to Change

Summary Diabetic Cohort Study

n=2599, 30% reduction in overall visits and 28% reduction

in overall billed charges for a total of $6,288,550 reduction

Pre and Post 180 days enrollment

Amb. Care Mgmt: Hgb A1C (n=961)

Compare lab values in

patient cohort 1 month prior

to ACM program enrollment

and 1 month prior to

program graduation date

Average 1

month prior to

program

enrollment:

Average

HbA1C: 9.50

Median HbA1C:

9.10

Average 1

month prior to

program

graduation:

Average

HbA1C: 7.04

Median HbA1C:

7.00

Statistically significant reduction in HbA1C is found pre and

post ACM program enrollment at group Level

ED High Utilizer Cohort

Ability to view

preventable ED visit

volume by hospital

Key metrics

including number of

visits and net

margin by age

bands

Preventable ED visit

detail by practice

attribution

Filter visit volume by

condition

Building Visibility

Filters for

preventable ED

category and

primary diagnosis

Ability to view

practice-level

volumes of

preventable ED

visits

Graphic illustration

of visit type by time

of day

Patient density

analysis by distance

to nearest ED

Use Data to Build Patient Population

List

Identifying Markers in the Data

• 30 or more visits within one

EMR

• 158 patients identified

• 7054 visits

• $22,022,370 charges

Payor Mix

• 2003 Self Pay

• 2084 Medicaid

• 918 Managed Care

• 464 Medicare Advantage

• 1560 Medicare

Craft Tactics

Game Plan

• Contact patients and enroll

within appropriate care

management programs

– Identify barriers to care

– Enroll in applicable programs

(BH, substance abuse, housing,

etc. )

– Keep ongoing contact

– 1

Data, YTD Feb

• Monthly roll call

– March 24th

Goal: Reduce Billed Charges

50%

Work as a Team

Running Man Intervention

• Data Analysis

• Who

• Payor

• Diagnosis

• Time of Day

• Then

– Patient Interview

– Structured data

collection

• interventions

Work as a Team

 ED Bouncing Ball Icon

 The icon will display on the FirstNet tracking

board in the Events column as soon as the

patient is registered to the ED.

 At the same time, a page/email will also be sent

to the CCM distribution list for each facility.

 The logic behind the icon and page is looking for

at least one Inpatient visit that was discharged

within 30 days of the current ED visit’s arrival

time.

See Results

• Based on the incredible work by the IAS Team and the Care

Management Team, there has been a 46% overall reduction in ED

admissions in three months.

• Existing resources at CHS are being leveraged to help this group

of patients. The Transitions Clinic is one example of how

repurposing could keep the ED admissions down and help us hit

our system goals.

• Systems are now in place to catch these patients that may have

fallen through the cracks previously due to bouncing around

locations, lower charges, lower numbers of inpatient admissions,

or lack of complex chronic or rising risk data screening.

Nurse Informaticists can ensure

proper translation and

communication

“The specialty that integrates nursing science with multiple

information management and analytical sciences to identify,

define, manage, and communicate data, information, knowledge,

and wisdom in nursing practice.

NI supports nurses, consumers, patients, the interprofessional

healthcare team, and other stakeholders in their decision-making

in all roles and settings to achieve desired outcomes.

This support is accomplished through the use of information

structures, information processes, and information technology.”

https://www.himss.org/what-nursing-informatics

Nursing Informaticists

• Validating data quality from external sources and ensure correct matching

• Understand current and future state workflow

• Operationalize how clinicians will use

• Support teams with change management through the transition

• Leverage Clinical Decision Support

– At the right time

– Meaningful alert

– Breakdown the data

– Example

• Understand business, financial, strategic impact to the organization

• Communicating differently

How can Nursing Informaticists

contribute?

• Registry Development

– Understand clinical processes

– Identify care gaps/workflow challenge

– Validate populations and measures

– Support providers around attribution

Example

Essential Organizational

Players and their Vital

Roles in Transitional Care

• Everyone plays (or will play) a role in Population Health!

• Key will be the requirement of a cultural shift and not “the way

we’ve always done it”

• Requires understanding of the bigger picture and the bigger

contribution

Essential Organization Players

Think di erently

• Sharing the EMR or view (not just sending pt with a paper packet)

• Extending your care coordination technologies (Seeing care that

occurs outside of your organizational walls, e.g. Patient Ping)

• Creating bi-directional feedback loops (Connecting with outside

resources, e.g.Connecting services for a patient with Aunt Bertha)

• Ensuring a feedback loop

• Connecting clinical leaders at both locations

• Care Management / Home Health (including from the payors) that

can assist in smoothing the processes – has to extend beyond the

traditional players

– E.g. aunt Bertha examples – faith based, don’t just be stuck

in nurse in acute and nurse in SNF

– Social determinants of health play a part in this and

understanding communities and the societal support

Their Vital Roles in Transitional Care

Alignment of Assets and Stakeholders

Physicians &

Providers

Post Acute

Patients

Leaders &

Associates

Acute Care

Facilities

Payers &

Employers

Ambulatory

We need to integrate all aspects of care to improve quality,

reduce costs and improve outcomes for the patients we serve.

Key Takeaways in

Identifying Source Data for

Specific Transitions of Care

Data across the continuum

Connect the

continuum

Empower

patients, care

teams,

and organizations

Facilitate

knowledge-driven

care

and continuous

learning

And many more…

• Faith based organizations

• Community resource organizations

• Patient self-management solutions

• Other potential business / health/ pharma / vendors will continue

to morph in this space

BE PREPARED to innovate or think outside the box!

Cross Continuum Care Management

Multi

-Disciplinary Team

• Highest ED utilizer in Atrium System for at least past 3 years

(over 1500 service/visits within Atrium Health

• Jan – April 2018 (120 calendar days), Joe has had 104 ED visits

• Other 16 days spent inpatient or observation

• ED, Inpatient, and Observation Facility Charges from 2015-2017

are over: $1,570,900

• YTD 2018 charges are $366,125

Joe’s Story

Meet Joe

• Joe comes to ED because of an

overwhelming fear he will die of

numerous different medical

ailments.

• He lives in a car and moves

between parking decks (CMC-

Main and Union) to have quick

access to the ED.

• Joe notes that the only thing that

helps him feel normal is coming to

the ED daily and having a doctor

reassure him that he will be fine.

• PTSD

• Overwhelming anxiety

• Hypochondriasis

• Major Depressive

Disorder

• Alcohol Use Disorder

New concept: Population Health version of Medical Ground Rounds

Launched on May 18, 2018

Multi-Disciplinary team meets monthly and present complex unresolved cases

Through critical thinking and collaboration an action plan is designed

Focused efforts to solve for self-imposed constraints and for absence of process

How do we know about Joe?

What did we do for Joe?

Care Team Meeting

PARC Staffing

Scheduled

Obtained Housing

(and sold his car)

Daily Behavioral

Health Therapy

Assigned to

Primary Care

Provider

Cell Phone, Food

Stamps,

Medicaid, SSI

Daily Community

Paramedicine

Update on Joe

“Yeah things are moving in the right

direction. Finely, I feel like a human again.”

Only 3 ED visits since Joe secured housing on June 12

• Understand your process drivers for defining the data you need

and don’t try to “boil the ocean”

• Leverage informaticists in the data aggregation and validation

processes

• Consider what each stakeholder needs to know and that the

information you share is actionable, or connected to automatic

actions

• Think differently

• Consider the patient holistically

• Share data to support the patient’s specific needs

Lessons Learned and Key Take Aways

from Our Organization

Contact information:

Becky G. Fox, MSN, RN-BC

Chief Nursing Informatics Officer

Becky.fox@atriumhealth.org

Linkedin: Becky Fox

Stephanie H. McIntyre, MBA, RN-BC, CRHQ

Assistant Vice President, Information and Analytics Services

Stephanie.mcintyre@atriumhealth.org

Linkedin: Stephanie H. McIntyre

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Questions